Deceased
Robert Dennis McIntosh
Demographics
55y, male
Coroner
Ryan
Date of death
2013-05-29
Finding date
2015-06-12
Cause of death
gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular carcinoma with portal vein thrombosis due to cirrhosis of the liver
AI-generated summary
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that medical care provided was appropriate and death could not have been prevented, significant system gaps were identified in managing chronic liver disease in prison populations. The case highlights the need for improved screening, monitoring, and treatment protocols for prisoners with hepatitis C and cirrhosis—particularly given the very high prevalence in custodial settings. Key clinical lessons include: earlier specialist surveillance for known hepatitis C and cirrhosis with ultrasound screening for hepatocellular carcinoma; better detection of subtle liver dysfunction markers; adoption of newer non-invasive testing such as Fibroscan; and establishment of standardised protocols across all correctional health services. The coroner emphasised the importance of coordinated systemic improvements rather than individual clinical failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
Procedures
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A 26-year-old man presented with chest and abdominal pain, initially diagnosed with possible hepatitis based on elevated liver function tests. He developed an atypical blanched rash not recognised as varicella zoster (ch…
45y · Male·Intra-abdominal haemorrhage due to ruptured spleen due to splenomegaly due to ci…
Hayward Rasmussen, a 45-year-old man with cirrhosis and severe splenomegaly, died from intra-abdominal haemorrhage due to ruptured spleen while in custody. He collapsed in prison after sustaining possible rib injuries fr…
57y · Male·Hepatic encephalopathy, end stage liver failure, alcoholic cirrhosis, end stage …
Gerry Maxwell Cooper, a 57-year-old Aboriginal man imprisoned for 23 years, died in PAH Secure Unit from natural causes: hepatic encephalopathy, end-stage liver failure, alcoholic cirrhosis, and end-stage renal failure. …
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